Street medicine, the practice of caring for homeless people outdoors,听is a burgeoning field 鈥� an unfortunate reality as America confronts a growing homelessness epidemic. But it鈥檚 at least become a little more rewarding after the Biden administration made an under-the-radar yet revolutionary change to Medicaid.
Starting this month, doctors, nurses and other providers can bill the program for low-income people for treating the homeless anywhere they are 鈥� indoors or听. Previously, Medicaid generally paid only for care delivered in traditional settings like hospitals, clinics and offices.
Now, practitioners of street medicine are asking for more:听higher Medicaid payment rates to reflect the cost of their services, which they say are far more labor-intensive and time-consuming than health care delivered at hospitals or clinics.
鈥淩ates have to reflect the difficulty of the work so this can be sustainable,鈥� said听Michelle Schneidermann, a street medicine expert who previously led homelessness initiatives at听Zuckerberg San Francisco General Hospital听and is now director of people-centered care at the听California Health Care Foundation.
Cities around the country are grappling with a听homelessness crisis听that is also a health-care crisis.听
People living outdoors are often听addicted to hard drugs and suffer from听mental illnesses and chronic diseases. At the same time, they鈥檙e notoriously difficult patients. Street medicine started gaining traction about 25 years ago, and today there are more than听150 programs听across the country, according to practitioners. At least听50听are in California.
Advocates for the homeless and the people who care for them say their medical needs have long been overlooked by the conventional health-care system and the institutions that pay for care, including the government.
鈥淭he way we treat people in health care is way different than how we approach people who are outside living under bridges and in encampments,鈥� says听Jim O鈥機onnell, who leads Boston鈥檚听,听one of the first street medicine programs in the country. 鈥淭his is a population that has more severe and persistent mental illness than any other group we know in America.鈥�
O鈥機onnell believes the new billing change could dramatically expand street medicine and integrate it into the current system of care 鈥� broadening the definition of听.听Yet much work has to be done to build infrastructure and get the industry on board, he said.
Some homeless people are already enrolled in Medicaid 鈥� usually in states that expanded the program under Obamacare. But many go uninsured even in states that have embraced the Affordable Care Act, and street medicine teams are poised to sign up patients they encounter in the field. Experts in one leading program in Los Angeles, for instance, say roughly听60 percent听of patients they encounter are already enrolled in Medicaid (a fraction that is probably far lower in other states). Once engaged by street medicine teams, the percentage rises to roughly听80 percent.听
Now that they can consistently bill Medicaid for their work, street medicine practitioners are planning a coordinated lobbying campaign to win higher payment rates, as well as a major PR effort to entice more providers and Medicaid health insurers to participate.听
But so far only听of practitioners are working around the country to build support.听They鈥檙e advocating for new legislation听; leading training and education initiatives with professional听听like the听American Academy of Family Physicians; and spreading the word about new billing mechanisms in states such as New Mexico.听
In California, a growing street medicine collaborative is pressing health insurers to contract directly with street medicine teams to make services more readily available.
鈥淭he next big thing in street medicine is boosting rates,鈥� said听Brett Feldman, a provider with听USC Street Medicine,听听to persuade the federal government to expand reimbursement. 鈥淚n street medicine, you鈥檙e out physically looking for your patients versus them coming to you, so it just takes longer. And it takes time to build trust.鈥�